Coronial
VIChospital

Finding into death of Tasman Murray Tribe

Deceased

Tasman Murray Tribe

Demographics

0y, male

Coroner

Coroner Simon McGregor

Date of death

2022-08-19

Finding date

2025-02-18

Cause of death

Complications of birth-related traumatic head injury

AI-generated summary

Tasman Murray Tribe, a neonate born at 36 weeks gestation, died at 7 days of age from complications of birth-related traumatic head injury. Labour was prolonged in the second stage; instrumental delivery was attempted but abandoned due to a deeply impacted fetal head. Emergency caesarean section was performed but the head could not be disimpacted easily despite appropriate senior clinician involvement and anesthetic support. Tasman was born in severe asphyxia with poor Apgar scores, requiring resuscitation and intensive care. He suffered extensive hypoxic-ischemic brain injury and multiorgan dysfunction. The coroner found the clinical management was appropriate and reasonable, executed by experienced staff in a timely manner. Key lessons include: ensuring comprehensive documentation of labour management; clear guidelines on recognizing and managing prolonged second stage labour; and incorporating difficult caesarean section scenarios (particularly fetal head disimpaction) into multidisciplinary emergency training and safety checklists for obstetric teams.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsneonatologypaediatricsanaesthesia

Drugs involved

oxytocinglyceryl trinitrate

Clinical conditions

pre-term pre-labour rupture of membranesprolonged second stage labourdeep transverse arrestimpacted foetal headfoetal asphyxiahypoxic ischaemic encephalopathysubarachnoid haemorrhagecerebral oedemacoagulopathyseizuresmultiorgan dysfunction

Procedures

instrumental deliveryventouse extractionemergency caesarean sectionfoetal head disimpactioncardiopulmonary resuscitationmechanical ventilationtherapeutic hypothermia

Contributing factors

  • Prolonged second stage of labour
  • Deep transverse arrest of fetal head
  • Deeply impacted fetal head at caesarean section
  • Difficult manual disimpaction procedure
  • Severe birth asphyxia
  • Hypoxic-ischemic brain injury

Coroner's recommendations

  1. Barwon Health to review policies and procedures for reporting sentinel events to ensure consistency with Safer Care Victoria's sentinel event guide
  2. Develop strategies to address inadequate and incomplete documentation to improve medical record practice
  3. Ensure current labour care guidelines and documentation templates align with best practice principles and identify gaps
  4. Ensure current guidelines include clear description of prolonged second stage of labour, its timely recognition and management
  5. Incorporate difficult caesarean section scenarios (particularly fetal head disimpaction) into multidisciplinary obstetric emergency training such as PROMPT
  6. Consider including impacted fetal head scenarios in operative vaginal birth and emergency caesarean section safety timeout checklists as recommended by CCOPMM
  7. Implement formal safety timeouts for instrumental birth and emergency caesarean section with multidisciplinary team assembly and clear escalation protocols
Full text
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